Lv Yong-Hui, Guo Chen, Li Min, Zhang Ming-Bo, Wang Zhi-Lu
The First Medical Clinical College of Lanzhou University.
Department of Cardiology, The First Hospital of Lanzhou University, Lanzhou, Gansu 730000, China.
Medicine (Baltimore). 2018 Nov;97(48):e13377. doi: 10.1097/MD.0000000000013377.
The modified double-stent and provisional stenting strategies have been widely used in patients with coronary bifurcation lesions, but what is the optimization has not been clearly defined. This meta-analysis is to elucidate the benefits from modified double-stent and provisional stenting strategies in patients with coronary bifurcation lesions.
Electronic databases were searched to identify studies comparing the modified double-stent and provisional stenting strategies in patients with coronary bifurcation lesions. The clinical outcomes were divided into early (≤6 months) and late (>6 months) events according to the follow-up duration. The early endpoints included cardiac death, myocardial infarction, target lesion revascularization or target vessel revascularization, and major adverse cardiac events (MACE), and the late endpoints also include stent thrombosis in addition to the early endpoints index. The angiographic endpoint was in-stent restenosis. Data were analyzed by the statistical software RevMan (version 5.3).
A total of 6 studies involving 1683 patients with coronary bifurcation lesions were included in this meta-analysis, which found that the modified double-stent strategy was associated with a lower risk of cardiac death (odds ratio [OR] = 0.29, 95% confidence intervals [CI] 0.11-0.78, P = .01), myocardial infarction (OR = 0.41, 95% CI 0.21-0.82, P = .01), target lesion revascularization or target vessel revascularization (OR = 0.31, 95% CI 0.15-0.63, P = .001), and MACE (OR = 0.41, 95% CI 0.22-0.74, P = .003) compared with provisional stenting in the early follow-up endpoint events, while the risk of cardiac death and stent thrombosis were similar between both strategies (OR = 0.59, 95% CI 0.31-1.10, P = .09; and OR = 0.62, 95% CI 0.34-1.15, P = .13; respectively) in the late follow-up endpoint events. There were significant differences between both strategies in myocardial infarction (OR = 0.42, 95% CI 0.24-0.75, P = .003), MACE (OR = 0.44, 95% CI 0.31-0.62, P < .00001), and target lesion revascularization or target vessel revascularization (OR 0.35, 95% CI 0.25-0.49, P < .00001) between both strategies in the late follow-up endpoint events. The risk of in-stent restenosis favored the modified double-stent strategy (OR 0.29, 95% CI 0.20-0.43, P < .00001).
The modified double-stent strategy is associated with excellent clinical and angiographic outcomes except for the occurrence of cardiac death and stent thrombosis late-term outcome compared with provisional stenting strategy in patients with coronary bifurcation lesions. These findings suggest that the modified double-stent strategy can be recommended as an optimization in patients with coronary bifurcation lesions.
改良双支架术和临时支架术策略已广泛应用于冠状动脉分叉病变患者，但最佳方案尚未明确界定。本荟萃分析旨在阐明改良双支架术和临时支架术策略在冠状动脉分叉病变患者中的益处。
检索电子数据库以识别比较改良双支架术和临时支架术策略治疗冠状动脉分叉病变患者的研究。根据随访时间将临床结局分为早期（≤6个月）和晚期（>6个月）事件。早期终点包括心源性死亡、心肌梗死、靶病变血运重建或靶血管血运重建以及主要不良心脏事件（MACE），晚期终点除早期终点指标外还包括支架血栓形成。血管造影终点为支架内再狭窄。采用统计软件RevMan（5.3版）进行数据分析。
本荟萃分析共纳入6项研究，涉及1683例冠状动脉分叉病变患者，结果发现，在早期随访终点事件中，与临时支架术相比，改良双支架术策略的心源性死亡风险较低（比值比[OR]=0.29，95%置信区间[CI]0.11 - 0.78，P=0.01）、心肌梗死风险较低（OR=0.41，95%CI 0.21 - 0.82，P=0.01）、靶病变血运重建或靶血管血运重建风险较低（OR=0.31，95%CI 0.15 - 0.63，P=0.001）以及MACE风险较低（OR=0.41，95%CI 0.22 - 0.74，P=0.003）；而在晚期随访终点事件中，两种策略的心源性死亡风险和支架血栓形成风险相似（分别为OR=0.59，95%CI 0.31 - 1.10，P=0.09；OR=0.62，95%CI 0.34 - 1.15，P=0.13）。在晚期随访终点事件中，两种策略在心肌梗死（OR=0.42，95%CI 0.24 - 0.75，P=0.003）、MACE（OR=0.44，95%CI 0.31 - 0.62，P<0.00001）以及靶病变血运重建或靶血管血运重建（OR 0.35，95%CI 0.25 - 0.49，P<0.00001）方面存在显著差异。支架内再狭窄风险有利于改良双支架术策略（OR 0.29，95%CI 0.20 - 0.43，P<0.00001）。
与临时支架术策略相比，改良双支架术策略在冠状动脉分叉病变患者中除心源性死亡和晚期支架血栓形成结局外，具有良好的临床和血管造影结果。这些发现表明改良双支架术策略可被推荐为冠状动脉分叉病变患者的优化方案。
